As described in the foregoing sections, modification of previous decisions is possible at many points in the policymaking process. In fact, modification of previous decisions characterizes the process. The role of policy modification can be seen vividly, for example, in the legislative history of the Medicare program. Imbedded in the chronology of Medicare-related legislation are many examples of how the modification phase of public policymaking plays out. The chronology of Medicare begins with the enactment of a new policy, the 1935 Social Security Act (P.L. 74-271), but from that point forward the establishment and continuation of the Medicare program is largely a matter of modifying previous policies.
The Medicare program emerged on the nation's policy agenda in large part through the operation of the Social Security program over a span of three decades, from the mid-1930s to the mid-1960s. President Franklin D. Roosevelt formed the Committee on Economic Security in 1934 and charged its members to develop a program that could ensure the "economic security" of the nation's citizens. The committee considered the inclusion of health insurance as part of the Social Security program from the outset. There was, in fact, strong sentiment for its inclusion among members of the committee (Starr 1982). But in the end they decided not to recommend the inclusion of health insurance because of the tremendous political burdens associated with such a proposal. The American Medical Association (AMA) in particular strongly opposed the concept (Peterson 1993).
As reflected in the original legislation, the objective embedded in the Social Security Act of 1935 was
... to provide for the general welfare by establishing a system of federal old age benefits, and by enabling the several States to make more adequate provision for aged persons, blind persons, dependent and crippled children, maternal and child welfare, public health, and the administration of their unemployment compensation laws. . . .
Although health insurance was not included among the program's original provisions, its addition was considered from time to time in the ensuing years. President Harry S. Truman considered national health insurance a key part of his legislative agenda (Altmeyer 1968). But AMA's continued powerful opposition and the necessity for the Truman administration to divert its attention to Korea in 1950 meant that President Truman was unable to stimulate the development and enactment of any sort of universal health insurance policy. Faced with dim political prospects for universal health insurance, proponents turned to a much more limited idea—hospital insurance for the aged.
Following a number of modest proposals for such insurance, none of which could muster the necessary political support for enactment, two powerful members of Congress, Senator Robert Kerr (D-Okla.) and Representative Wilbur Mills (D-Ark.), were able to see through to passage a bill that provided federal support for states' programs in welfare medicine. The Amendments to the Social Security Act of 1960 (P.L. 86-778) provided health benefits to the aged, although only to those who were poor. Not until the Democratic margin in Congress was significantly increased in President Lyndon B. Johnson's landslide election in 1964 did a more expansive initiative have much chance of passage. Key events leading up to the enactment of Medicare can be read at http://www.cms.hhs.gov/about/history/corningappa.asp (CMS 2004).
With Medicare's prospects significantly improved by the 1964 election, it received a very high priority among President Johnson's Great Society programs and was enacted as part of the Social Security Amendments of 1965 (P.L. 89-97). Medicare emerged on the nation's policy agenda through a series of attempts to modify the original Social Security Act by expanding the benefits provided to include health insurance. Although these attempts at modifying the original Social Security Act failed more often than not, they set the stage for the eventual modification that resulted in the Medicare program. As Peterson (1997, 292) notes, "The (policy) choices of one period are intimately linked to the choices grasped or missed in a previous era."
Following the original enactment of the legislation establishing the Medicare program, the chronology of related legislation shows a remarkable pattern of the evolutionary, incremental modification of a single, although massive, public policy. In a progression of modifications that continues today, among other changes, services for Medicare beneficiaries have been added and deleted; premiums and copayment provisions have been changed; reimbursement rates and payment mechanisms for service providers have been changed; and features to ensure quality and medical necessity of services have been added, changed, and deleted.
The legislative chronology of the Medicare program reflects significant legislative change from year to year, a pattern likely to continue so long as this complex and expensive program exists. The pattern of modifications exhibited in the Medicare legislation, chronicled in the lists that follow, has been heavily influenced by ongoing experience with the implementation of the original legislation and its subsequent modifications. This list illustrates how Medicare policy has been modified extensively over the course of the program's life and emphasizes the role that the modification phase plays in the overall policymaking process.
• 1935: Social Security Act (P.L. 74-271). This landmark legislation, enacted during the Great Depression, initiated the expansion of the federal government's central role in the domain of social insurance. Importantly, for the future of federal health policy, it included provisions through which the federal government made grants in aid to states for the support of programs for the needy elderly, dependent children, and the blind. Over the years, a number of amendments were made to the act, including the amendments of 1960 (P.L. 86-778), known as the Kerr-Mills Act, which established a new program for medical assistance for the aged.
• 1965: Social Security Amendments (P.L. 89-97). This legislation provided health insurance for the aged through Title XVIII (Medicare) and provided grants to the states for medical assistance programs for the poor through Title XIX (Medicaid).
Part A of Medicare provided hospital insurance benefits intended to protect beneficiaries against certain costs of hospital and related posthospital services. These benefits were financed by an increase in the Social Security earnings (payroll) tax. Part B of Medicare provided supplemental medical insurance benefits intended to protect beneficiaries from the costs of certain physician services, laboratory tests, supplies, and equipment, as well as certain home health services. These benefits were financed by voluntary premium payments from those who chose to enroll, matched by payments from general revenues.1
• 1967: Social Security Amendments (P.L. 90-248). The first modifications to the Medicare program, coming two years after its establishment, expanded coverage for such aids as durable medical equipment for use in the home, podiatrist services for nonroutine foot care, and outpatient physical therapy under Part B, and the addition of a lifetime reserve of 60 days of coverage for inpatient hospital care over and above the original coverage for up to 90 days during any spell of illness.
In addition, certain payment rules were modified in favor of providers. For example, payment of full reasonable charges for radiologists' and pathologists' services provided to inpatients was authorized under one modification.
• 1972: Social Security Amendments (P.L. 92-603). Although in part these changes continued the pattern of program expansions started in the 1967 modifications, they marked an important shift to some policy modifications that were intended specifically to help control the growing costs of the Medicare program. Among the most important of the 1972 modifications was the establishment of professional standards review organizations (PSROs), which were to monitor both the quality of services provided to Medicare beneficiaries and the medical necessity for the services.
Another modification aimed at cost containment was the addition of a provision to limit payments for capital expenditures by hospitals that had been disapproved by state or local planning agencies. Still another was the authorization of grants and contracts to conduct experiments and demonstrations related to achieving increased economy and efficiency in the provision of health services. Some of the specifically targeted areas of these studies included prospective reimbursement, the requirement that patients spend three days in the hospital prior to admission to a skilled nursing home, the potential benefits of ambulatory surgery centers, payment for the services of physician assistants and nurse practitioners, and the use of clinical psychologists.
At the same time that these and other cost-containment modifications were made in the Medicare policy, a number of cost-increasing changes were also made. Notably, persons who were eligible for cash benefits under the disability provisions of the Social Security Act for at least 24 months were made eligible for medical benefits under the Medicare program. In addition, those who were insured under Social Security, as well as their dependents, who required hemodialysis or renal transplantation for chronic renal disease were defined as disabled for the purpose of covering them under the Medicare program for the costs of treating their end-stage renal disease (ESRD). The inclusion of coverage for the disabled and ESRD patients in 1972 represented extraordinarily expensive modifications of the Medicare program. In addition, certain less costly but still expensive additional coverages were extended, including chiropractic and speech pathology services.
• 1976-77: A major reorganization of the U.S. Department of Health, Education, and Welfare (now the U.S. Department of Health and Human Services). Although not technically a modification of the Medicare policy, this reorganization resulted in the establishment of the Health Care Financing Administration (HCFA), an agency within DHEW (now DHHS) that assumed primary responsibility for implementation of the Medicare and Medicaid programs. This new agency combined functions that had been located in the Bureau of Health Insurance of the Social Security Administration (Medicare) and in the Medical Services Administration of the Social and Rehabilitation Service (Medicaid), among others.
• 1977: Rural Health Clinic Services Amendments (P.L. 95-210). This legislation modified the categories of practitioners who could provide reimbursable services to Medicare beneficiaries in rural settings. Under the provisions of this act, rural health clinics that did not routinely have physicians available on site could, if they met certain requirements regarding physician supervision of the clinic and review of services, be reimbursed through the Medicare and Medicaid programs for services provided by nurse practitioners and physician assistants. This act also authorized certain demonstration projects in underserved urban areas for reimbursement of these nonphysician practitioners.
• 1977: Medicare-Medicaid Antifraud and Abuse Amendments (P.L. 95-142). These modifications were intended to reduce fraud and abuse in both the Medicare and Medicaid programs and thereby help contain their costs. Specific changes included strengthening criminal and civil penalties for fraud and abuse, modifying the operations of the PSROs, and promulgating uniform reporting systems and formats for hospitals and certain other healthcare organizations participating in the Medicare and Medicaid programs.
• 1978: Medicare End-Stage Renal Disease Amendments (P.L. 95-292). Since the addition of coverage for ESRD under the Social Security Amendments of 1972 (P.L. 92-603), the costs to the Medicare program had risen steadily and quickly. These amendments sought to help control the program's costs. One modification added incentives to encourage the use of home dialysis and renal transplantation in ESRD. Another modification permitted the use of a variety of reimbursement methods for renal dialysis facilities. Still another modification authorized studies of ESRD itself, especially studies incorporating possible cost reductions in treatment for this disease, and authorized the Secretary of DHEW (now DHHS) to establish areawide network coordinating councils to help plan for and review ESRD programs.
• 1980: Omnibus Budget Reconciliation Act, or OBRA '80 (P.L. 96-499). Extensive modifications of Medicare and Medicaid policy were made in this legislation. Fifty-seven separate sections pertained to one or both of the programs. Many of the changes reflected continuing concern with the growing costs of the programs and were intended to help control these costs. Examples of the changes that were specific to Medicare included removal of the 100-visits-per-year limitation on home health services and the requirement under Part B that patients pay a deductible for home care visits. These changes were intended to encourage home care rather than more expensive institutional care. Another provision permitted small rural hospitals to use their beds as "swing beds" (alternating their use as acute or long-term-care beds as needed) and authorized swing-bed demonstration projects for large and urban hospitals.
• 1981: Omnibus Budget Reconciliation Act, or OBRA '81 (P.L. 97-35). Just as in 1980, this legislation included extensive changes in the Medicare and Medicaid programs (46 sections pertained to these programs). Enacted in the context of extensive efforts to make reductions in the federal budget, many of the provisions hit Medicaid especially hard, but others were aimed directly at the Medicare program. For example, one provision eliminated the coverage of alcohol detoxification facility services, another removed the use of occupational therapy as a basis for initial entitlement to home health services, and yet another increased the Part B deductible.
• 1982: Tax Equity and Fiscal Responsibility Act, or TEFRA (P.L. 97-248). A number of important changes with significant impact on the Medicare program were contained in this legislation. For example, one provision added coverage for hospice services provided to Medicare beneficiaries. These benefits were extended later and are now an integral part of the Medicare program. However, the most important provisions, in terms of impact on the Medicare program, were those that sought to control the program's costs by setting limits on how much Medicare would reimburse hospitals on a per-case basis and by limiting the annual rate of increase for Medicare's reasonable costs per discharge. These changes in reimbursement methodology represented fundamental changes in the Medicare program and reflected a dramatic shift in the nation's Medicare policy. Another provision of TEFRA pertained to replacing PSROs, which had been established by the Social Security Amendments of 1972 (P.L. 92-603), with a new utilization and quality control program called peer review organizations (PROs). The TEFRA changes regarding the operation of the Medicare program were extensive, but they were only the harbinger of the most sweeping legislative changes in the history of the Medicare program the following year.
• 1983: Social Security Amendments (P.L. 98-21). This important legislation initiated the Medicare prospective payment system (PPS) and included provisions to base payment for hospital inpatient services on predetermined rates per discharge for diagnosis-related groups (DRGs). PPS was a major departure from the cost-based system of reimbursement that had been used in the Medicare program since its inception in 1965. The dramatic impact of this change on Medicare is best seen in terms of hospital expenditures, which were reduced sharply. An analysis by Russell and Manning (1989) shows that 1990 Medicare expenditures for hospital inpatient care were approximately 20 percent lower than they would have been without implementation of PPS. In this act, Congress directed the Reagan administration to study physician payment reform options.
• 1984: Deficit Reduction Act, or DEFRA (P.L. 98-369). Among the provisions of this act was one to temporarily freeze physicians' fees paid under the Medicare program. Another placed a specific limitation on the rate of increase in the DRG payment rates that the secretary of DHHS could permit in the two subsequent years. This act also created two classes of physicians in regard to their relationships to the Medicare program and outlined different reimbursement approaches for them depending on whether they were classified as participating or nonparticipating.
• 1985: Emergency Deficit Reduction and Balanced Budget Act, or the Gramm-Rudman-Hollins Act (EL. 99-177). This legislation established mandatory deficit reduction targets for the five subsequent fiscal years. Under provisions of the law, the required budget cuts would come equally from defense spending and from domestic programs that were not exempted. The Gramm-Rudman-Hollins Act had significant impact on the Medicare program throughout the last half of the 1980s, as well as on other health programs such as community and migrant health centers, programs for veterans and Native Americans, health professions education, and NIH (Rhodes 1992). Among other actions, this legislation led to substantial cuts in Medicare payments to hospitals and physicians.
• 1985: Consolidated Omnibus Budget Reconciliation Act, or COBRA '85 (P.L. 99-272). Through a number of provisions of the act that affected Medicare, hospitals that served a disproportionate share of poor patients received an adjustment in their PPS payments; hospice care was made a permanent part of the program; FY 1986 PPS payment rates were frozen at 1985 levels through May 1, 1986, and increased 0.5 percent for the remainder of the year; payment to hospitals for the indirect costs of medical education were modified; and a schedule to phase out payment of a return on equity to proprietary hospitals was established.
• 1986: Omnibus Budget Reconciliation Act, or OBRA '86 (P.L. 99-509). This act altered the PPS payment rate for hospitals once again and reduced payment amounts for capital-related costs by 3.5 percent for part of FY 1987, by 7 percent for FY 1988, and by 10 percent for FY 1989. In addition, certain adjustments were made in the manner in which "outlier," or atypical, cases were reimbursed.
• 1987: Omnibus Budget Reconciliation Act, or OBRA '87 (P.L. 100-203). This legislation required the secretary of DHHS to update the wage index used in calculating hospital PPS payments by October 1, 1990 and to do so at least every three years thereafter. It also required the Secretary to study and report to Congress on the criteria being used by the Medicare program to identify referral hospitals. Deepening the reductions established by OBRA '86, one provision of the act reduced payment amounts for capital-related costs by 12 percent for FY 1988 and 15 percent for FY 1989.
• 1988: Medicare Catastrophic Coverage Act (P.L. 100-360). This act provided the largest expansion of the benefits covered under the Medicare program since its establishment in 1965. Among other provisions, this act added coverage for outpatient prescription drugs and respite care and placed a cap on out-of-pocket spending by the elderly for copayment costs for covered services. The legislation included provisions that would have the new benefits phased in over a four-year period and paid for by premiums charged to Medicare program enrollees. Thirty-seven percent of the costs were to be covered by a fixed monthly premium paid by all enrollees, and the remainder of the costs were to be covered by an income-related supplemental premium that was, in effect, an income surtax that would apply to fewer than half of the enrollees. Under intense pressure from many of their elderly constituents and their interest groups, who objected to having to pay additional premiums or the income surtax, Congress repealed P.L. 100-360 in 1989 without implementing most of its provisions.
• 1989: Omnibus Budget Reconciliation Act, or OBRA '89 (PL. 101-239). The act included provisions for minor, primarily technical, changes in PPS and provisions to extend coverage for mental health benefits and add coverage for Pap smears. Small adjustments were made in the disproportionate share regulations, and the 15 percent capital-related payment reduction established in OBRA '87 was continued in OBRA '89. Another provision required the secretary of DHHS to update the wage index annually in a budget-neutral manner beginning in FY 1993. The most important provision of OBRA '89 was one through which HCFA was directed to begin implementing a resource-based relative value scale (RBRVS) for reimbursing physicians under the Medicare program on January 1, 1992. The new system was to be phased in over a four-year period beginning in 1992.
• 1990: Omnibus Budget Reconciliation Act, or OBRA '90 (P.L. 101-508). The act made additional minor changes in PPS, including further adjustments to the wage index calculation and the disproportionate share regulations. Regarding the wage index, one provision required the Prospective Payment Assessment Commission (ProPAC), which was established by the 1983 Amendments to the Social Security Act to help guide Congress and the secretary of DHHS on implementing PPS, to further study the available data on wages by occupational category and to develop recommendations on modifying the wage index to account for occupational mix. It also included a provision that continued the 15 percent capital-related payment reduction that was established in OBRA '87, and continued in OBRA '89, and included another provision that made permanent the reduced teaching adjustment payment established in OBRA '87. One of its more important provisions provided a five-year deficit reduction plan that was to reduce total Medicare outlays by more than $43 billion between FY 1991 and FY 1995.
• 1993: Omnibus Budget Reconciliation Act, or OBRA '93, (P.L. 103-66). This legislation established an all-time record five-year cut in Medicare funding and included a number of other changes affecting the Medicare program. For example, the legislation included provisions to end return on equity (ROE) payments for capital to proprietary skilled nursing facilities and reduced the previously established rate of increase in payment rates for care provided in hospices. In addition, the legislation cut laboratory fees drastically by changing the reimbursement formula and froze payments for durable medical equipment, parenteral and enteral services, and orthotics and prosthetics in FY 1994 and FY 1995.
It should be noted that the period 1993-96 was a unique time in the legislative history of the Medicare program—indeed, for health policy in general. The intense focus on President Clinton's attempt to reform the American healthcare system through his Health Security Act, which was introduced in late 1993 and died with the 1994 Congress (Hacker and Skocpol 1997; Hacker 1997), meant that little legislative energy was available for other health-related legislation. The hiatus in significant health policy continued following the Health Security bill's demise. Intense efforts in 1995 to enact unprecedented cutbacks in the Medicare and Medicaid programs as part of a far-reaching budget reconciliation bill ended in a veto by President Clinton.
The budget battle grew even worse in 1996. Proposed changes in the Medicare program, changes that were linked to the development of a plan to balance the federal budget over a seven-year span, would have meant massive cuts in the program. But political and philosophical differences over these plans between the Republican-controlled Congress and President Clinton, a Democrat, were so fundamental that they led to a complete impasse in the budget negotiations in 1996, including a brief shutdown of the federal government in the absence of budget authority to operate. Stung by public criticism of the disruptive budget battle of 1996, Congress resumed its normal schedule in developing the budget legislation in 1997. The result continued the significant pattern of modification in the Medicare program.
• 1997: Balanced Budget Act of 1997 (BBA) (P.L. 105-33). This legislation contained the most significant changes in the Medicare program since the program's inception in 1965. Overall, it requires a five-year reduction of $115 billion in the Medicare program's expenditure growth and a $13 billion reduction in growth of the Medicaid program. The Medicare+Choice program was created, which gives Medicare beneficiaries the opportunity to choose from a variety of health plan options the one that best suits their needs and preferences. Significant changes were also made in the traditional Medicare program. Among them, hospital annual inflation updates were reduced, as were hospital payments for inpatient capital expenses and bad debts. Other provisions established a cap on the number of medical residents supported by Medicare graduate medical education (GME) payments and provided incentives for reductions in the number of residents.
An important provision of this act established the State Children's Health Insurance Program (SCHIP) and provided states with $24 billion in federal funds for the period 1998 to 2002 to increase health insurance for children. Other provisions established two new commissions. One ofthese, the Medicare Payment Advisory Commission (MedPAC) replaced the Physician Payment Review Commission and the Prospective Payment Review Commission. MedPAC was required to submit an annual report to Congress on the status of Medicare reforms and make recommendations on Medicare payment issues. A second new commission, the National Bipartisan Commission on the Future of Medicare, was established by this legislation and charged to develop recommendations for Congress on actions necessary to ensure the long-term fiscal health of the Medicare program. This commission was charged to consider several specific issues that were debated in the development of the BBA of 1997 but rejected. These issues included raising the eligibility age for Medicare, increasing the Part B premiums, and developing alternative approaches to financing GME.
The National Bipartisan Commission on the Future of Medicare concluded its work and released its final report, Building a Better Medicare for Today and Tomorrow, on March 16, 1999. The report contains three sets of recommendations: (1) the design of a premium support system for the Medicare program, (2) improvements to the current Medicare program, and (3) financing and solvency of the Medicare program. The key recommendations ofthe commission, however, could not gather the bipartisan support necessary for amending the Medicare policy.
As BBA began to be implemented, health interest groups affected by the law, including the American Hospital Association, mounted an intense lobbying campaign to reverse some of BBA's effects. The campaign was made easier because the nation's budget surplus was growing at an unexpected rate. Two important health-related laws were enacted to modify BBA.
• 1999: Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) (P.L. 106-113). This legislation changed the BBA provisions in a number of ways. For example, hospitals treating a disproportionate share (DSH) of low-income Medicare and Medicaid patients receive additional payments from Medicare. BBRA froze DSH adjustments at 3 percent (the FY 2000 level) through FY 2001, reduced the formula to 4 percent from the BBA-established 5 percent in FY 2002, and mandated a 0 percent level for subsequent years. The law increased hospice payment by 0.5 percent for FY 2001 and by 0.75 percent for FY 2002. Medicare reimburses teaching hospitals for their role in providing GME. Prior to BBA, Medicare's indirect medical education (IME) adjustment payments increased 7.7 percent for each 10 percent increase in a hospital's ratio of interns and residents to beds. BBA decreased the adjustment to 6.5 percent in FY 1999, 6.0 percent in FY 2000, and 5.5 percent in FY 2001 and subsequent years. BBRA froze the IME adjustment at 6.5 percent through FY 2000, reduced it to 6.25 percent in FY 2001, and reduced it to 5.5 percent in FY 2002 and subsequent years.
• 2000: Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (P.L. 106-554). This legislation was attached as an amendment to that year's appropriations bill and signed into law by President Clinton on December 21, 2000. It effectively changed a number of provisions previously enacted in BBA and BBRA. Among the important changes were o an increase of 3.4 percent for Medicare inpatient payments in FY
2001 and an estimated 3.5 percent in FY 2002;
o an increase of 4.4 percent in Medicare outpatient payments in 2001; o IME payments at 6.5 percent in FY 2001 and FY 2002; o elimination of the additional 1 percent cut in Medicare DSH hospital payments in FY 2001 and 2002; o an increase from 55 to 70 percent in Medicare payments for bad debt; o an increase for the direct GME payment floor to 85 percent of the national average; o elimination of BBA's FY 2001 and 2002 Medicaid DSH cut; o removal of the 2 percent payment reduction for rehabilitation hospitals in FY 2001; o a 3.2 percent increase in skilled nursing service payments in FY 2001; o a one-year delay of the 15 percent reduction for home health and the full market basket in FY 2001; o an increase of 3 percent in incentive payments for psychiatric hospitals/units; and o expansion of Medicare payment for telehealth services to rural areas.
In the 107th Congress, the Medicare debate centered on the addition of an outpatient prescription drug benefit to the program; legislation providing the benefit was enacted in the 108th Congress. The lack of coverage for more than one in four beneficiaries and continued increases in drug expenditures led to several proposals, culminating in the enactment on December 8, 2003 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This law contained the most significant changes in the Medicare program since its enactment in 1965. Full implementation of the law was scheduled to take place over several years.
• 2003: Medicare Prescription Drug, Improvement, and Modernization Act of2003 (MMA) (P.L. 108-173). This law created a new drug benefit as Part D of Medicare. The new benefit begins in 2006, with an interim Medicare-endorsed drug discount card available to beneficiaries. In addition, this law adds certain preventive benefits including an initial routine physical examination for new beneficiaries, cardiovascular blood screening tests, and diabetes screening and services. MMA also renamed Medicare+Choice to Medicare Advantage (MA) and changed some of the enrollment and disenrollment rules for beneficiaries.
Another fundamental change in the Medicare program resulting from MMA is the Part B premium determination, which has been uniform for all beneficiaries since the program's inception. Beginning in 2007, this premium will be higher for those with an income over $80,000 for a single beneficiary, or over $160,000 per couple. In addition, the Part B deductible, set at $100 since 1991, is increased to $110 and thereafter will increase by the annual percentage increase in Part B expenditures.
• 2005: Final Rule Implementing MMA. The Centers for Medicare & Medicaid Services (CMS) issued the final rule implementing MMA on January 21, 2005. A comprehensive summary of the final rule to implement the prescription drug benefit can be read at http://www.kff.org/medicare/upload/51141_1.pdf.
In the 109th Congress (2005-06), efforts to modify Medicare policy continue apace. For example, S. 222 seeks to amend Title XVIII of the Social Security Act to stabilize the amount of the Medicare Part B premium; S. 445 seeks to amend Part D of Title XVIII of the Social Security Act, as added by MMA, to provide for negotiation of fair prices for Medicare prescription drugs; and H.R. 868 seeks to amend Title XVIII of the Social Security Act to improve the provision ofitems and services provided to Medicare beneficiaries residing in rural areas.
Indeed, modification is a ubiquitous component of the overall policymaking process, as the chronology of modification in Medicare policy clearly illustrates. With this as background, attention turns in the next section to two structural aspects of the modification phase of policymaking.
Was this article helpful?
Achieve the Fitness and Wellness for You that you have always wanted by learning the facts so you can take the right steps to maximize your health. Learn How to Achieve Real Fitness and Wellness for a Healthy Body, Mind and Spirit to Improve Your Quality of Life in Today's World. Receive Valuable Information to Discover What Really Matters and What Actually Works in Finding Genuine Wholeness for All Aspects of Your Being.